Wednesday, June 29, 2016

IBM Medicare prescription drug insurance off label drug coverage

Every year - EVERY YEAR - it is really important to reevaluate your prescription drug insurance plan coverage to ensure you are getting the best coverage at the least annual cost during Medicare Fall Enrollment which occurs October 15 to December 7.
I recently listened to a Medicare recipient bitterly complain about how much work it is to manage her IBM Medicare insurance options, claims and enrollment.  She said she was retired and she wanted IBM to take care of this stuff for her!  I must admit it was irksome.  Even when IBM provided us with Medicare group health insurance, it was always important to evaluate the options they presented and determine the "best fit" choice.  So, as the slogan dictates, JUST DO IT!  If you ignore it, it can and will come back and bite you.  If you need help doing it, involve your relatives or find support organizations through Department of the Aging in your state to get advice.
The 2016 Medicare Fall enrollment session is right around the corner and will give you the opportunity to consider your plan choices for 2017.  This year has been a rough prescription drug coverage year for a lot of Medicare users whether the drug insurance coverage was provided through a Medicare part D stand alone insurance policy or a Medicare Advantage plan.  Beginning January 2016, prescription drug insurance companies were instructed by Medicare to clamp down on prescriptions prescribed for "off label" use and were told to deny such coverage.
What is "off label"?  All prescription drugs go onto the market because the pharmaceutical company proved the drug worked to treat a given condition.  Sometimes, the drug is only useful for that condition.  As an example, as far as I know, insulin's purpose is to treat diabetes.  That's the use which has been approved by the FDA.  If your doctor decided to prescribe insulin to treat some other condition, no matter how effective it might be, it would be an "off label"  use.

There are a lot of drugs that are only approved for a specific use or for a specific population.  For example, drugs used to treat Attention Deficit Disorder such as Adderall are FDA approved for CHILDREN meaning they are not approved for people older than 18.  Drug companies did not prove the usefulness for adults.  But adults can have the condition.  If the drug is prescribed it will be DENIED because of the instructions Medicare gave to the insurance companies. The only exception is if the disease being treated is cancer.
Why does Medicare have this power?  Medicare subsidizes private insurance companies.  Simply said, the government gives private insurance companies money every time you use a drug.  If you never use drugs then the insurance company does not get the subsidy (they just get your premium).
Why is all this blah, blah, blah relevant to you?  Just because a prescription drug plan has a drug on its formulary, it doesn't mean they will cover the drug.  The drug is only covered by insurance if it is used for the FDA approved condition.  There is no sense entering that drug when you do your plan selection in October unless you get a written guarantee from the drug insurance company that it will be covered.  Fat chance with that but maybe you want to try to get it for non-cancer related conditions.  You will highly likely have to pay full cost for the drug or try to find other discount options by asking the pharmaceutical company.

The bottom line is to pick a plan to cover your "on label" drugs unless the drug is used to treat cancer.
This post is long enough so I'll end it here.  Just a quick reminder - OneExchange sells a SUBSET of the prescription insurance plans available to you in your zip code.  If you are using original Medicare, AND you buy a Medicare Supplement through OneExchange, look at all the part D insurance options on to make the best choice.